Pneumothorax

10cm
 Pneumothorax
Abnormal collection of
air in pleural space

Collapsed lung
10cm 2
Classification
Pneumothorax

Spontaneous Traumatic

Primary Secondary Iatrogenic Non Iatrogenic

Positive Penetrating Blunt

Interventional
pressure trauma trauma
procedure
ventilation

10cm 3
 Primary spontaneous pneumothorax

● without underlying lung disease

● Mostly in young men, 20-40 years old
● Incidence 18-28/100,000 in male, 1.2-6/100,000 in female

10cm 4
 Risk factor

Genetic: HLA A2,B40

Cigarette smoking (Autosomal dominant)

10cm rapid height increase during childhood 5

 Etiology

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 Pathophysiology

10cm 7
 ● Respiratory center
○ Increased respiratory rate (hypoxemia, PaCO2 in COPD
patient)
● Lung
○ Decrease in lung volume due to increased pleural pressure
○ Low V/Q mismatch
○ Shunt increase
○ Muscle fatigue (respiratory muscle)
○ Decrease in vital capacity
● Cardiovascular
○ Decrease in PaO2
○ Decreased venous return -> Decreased cardiac output ->
10cm
increased Heart rate 8
 Clinical presentation
- Sudden pleuritic chest pain (pricking like, cutting like)
- Dyspnea : collapsed lung and vital capacity decrease
- Dry cough : Air stimulates pleura
- Diminished breath sound
- Hyperresonance

10cm 9
 Physical examination
● Inspection
○ Distended neck vein
○ Unilateral chest movement
● Palpation
○ Tracheal deviation to opposite if much air
○ Decreased to absent tactile fremitus
● Percussion
○ Hyperresonance
○ Hypertympanic sound over the affected side
● Auscultation
○ Decreased to absent breath sound on affected side
○ No adventitious sound
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 Secondary spontaneous pneumothorax

● with underlying lung disease

- COPD and Bullous disease
● Mostly in 60 - 70 years old
● More morbidity and mortality compared to PSP

10cm 11
 Marfan syndrome

10cm
Mitral valve prolapse 12
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10cm 14
 Traumatic pneumothorax
● Iatrogenic pneumothorax
- Interventional procedure, PPV, C-line
● Non-iatrogenic
- Blunt and penetrating trauma

10cm 15
10cm 16
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10cm Ref X-Ray Exp / 18
 Tension pneumothorax

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10cm Ref X-Ray Exp / 20
 Clinical presentation
- Sudden pleuritic chest pain (pricking like, cutting like)
- Dyspnea : collapsed lung and vital capacity decrease
- Dry cough : Air stimulates pleura
- Diminished breath sound
- Hyperresonance

10cm 21
 Diagnosis

Chest radiography CT chest Ultrasound

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 Chest radiography

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10cm Ref X-Ray Exp / 24
 ● ACCP
● Small < 3 cm
● Large >= 3 cm
● BTS
● Small < 1 CM
● Moderate 1-2 cm
● Large > 2 cm

10cm 25
 CT chest

10cm 26
 Ultrasound

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 Management
- Observation
- Aspiration
- Tube thoracostomy
- Pleurodesis
- Surgery

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 Management

Goals Treatment option

- Promote lung expansion
- Eliminate the pathogenesis
- Decrease pneumothorax recurrence
- Severity of disease
- The extension of lung collapse
- Classification of pneumothorax
- Pathogenesis
- Pneumothorax frequency
- Complication and concomitant underlying
disease

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10cm 30
10cm 31
 Aspiration

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Tube thoracostomy

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 Indication for surgery
● Second ipsilateral pneumothorax.
● First contralateral pneumothorax.
● Synchronous bilateral spontaneous pneumothorax.
● Persistent air leak (despite days of chest tube drainage) or failure
of lung re-expansion.
● Spontaneous haemothorax.
● Professions at risk (eg, pilots, divers).
● Pregnancy
● Absence of medical facilities in isolated areas

10cm 34
 Video assisted thoracoscopic surgery
(VATS)

10cm 35
 Open thoracotomy

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 Pleurodesis

Recurrent rate

- Higher in Female, smoking, history of

recurrent pneumothorax
- Not associated with size of pneumothorax
10cm and amount of bleb/bullae 37
Tension pneumothorax and unstable patients
● Supplemental oxygen
● Immediate chest tube thoracostomy:
○ A catheter is inserted into the chest wall
○ Placed in the 4th to 5th intercostal space at the midaxillary line
● Needle decompression if chest tube placement needs to be delayed (e.g., prehospital care):
○ 14- or 16-gauge needle is inserted through the chest wall.
○ 2nd or 3rd intercostal space in the midclavicular line
○ 5th intercostal space in the anterior or midaxillary line is another option.
○ Should be followed by chest tube placement.

10cm Ref X-Ray Exp / 38

 PSP

Small pneumothorax & no significant breathlessness

- Observe
- Consider discharge review in OPD in 2-4 weeks
- advice to return in the event of worsening breathlessness.
- ensure satisfactory resolution and reinforce the advice on lifestyle.

significant breathlessness (tension pneumothorax)

- supplemental high flow oxygen(4x increase in the rate of pneumothorax resolution)

- Needle aspiration (reduced hospitalization and length of stay/ failure rate high ⅓ ) +
heimlich valves and suction(persistent air leak with or without incomplete re-expansion
of the lung—> reason for consideration of the use of suction high volume low pressure
- Failed NA, small-bore chest drain insertion (less painful similar success to large bore
- Refer to respiratory physician in 24 h.

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 SSP (air leak is less likely to settle spontaneously)

- Oxygen (caution in patient with carbon dioxide retention)

- Aspiration less likely to be successful. Can be use in small pneumothoraces
- Small bore chest drain
- Persistent air leak should be discuss with a thoracic surgeon after 48 h.

Patient with ssp but unfit for surgery

● Virtue of the severity of underlying lung disease

● Medical Pleurodesis (ambulatory mx with use of a heimlich valve

Discharge &f/u

● Return if breathlessness
● Follow up by a respiratory physician
● Lifestyle advice
● Observation or na should return for a follow up cxr after 2-4 weeks
●
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supplemental high flow oxygen

PSP
Small pneumothorax & no significant breathlessness
- Observe
- Consider discharge review in OPD in 2-4 weeks
- advice to return in the event of worsening breathlessness.
- ensure satisfactory resolution and reinforce the advice on lifestyle.
-

Chest drains are usually required for patients with

tension or bilateral pneumothorax who should be
admitted to hospital

10cm Ref X-Ray Exp / 41

supplemental high flow oxygen

- Chemical pleurodesis
- Higher recurrent rate than surgical treatment (open , VATS) 10-20%
- Use in patient too frail for surgery or unwilling to undergo surgical
treatment
- Tetracycline, minocycline and doxycycline
- Tetracycline 500 mg
- Intrapleural local anesthesia: 250mg of 1% lidocaine

10cm Ref X-Ray Exp / 42

 Surgical
● Recurrent rate less
● Indication for surgical advice

Surgical
● 2 objective
○ Resection any visible bullies or blobs
○ Create a symphysis between the two opposing pleural surface of
the visceral pleura
● VATS
○ lower mobility
○ Total economic cost of vats was lower
○ Undertaken without general anesthesia
○ Improved pulmonary gas exchange potoperatively
● Open thoracotomy with pleural abrasion
○ Lowest pneumothorax recurrent rates
○ Greater blood loss
10cm
○ More postoperative pain Ref X-Ray Exp / 43
○ Longer hospital stays
 Surgical chemical pleurodesis
● 5 g sterile graded talc
● Ards (relates to the size of talc particles) ที่ไม sterilised
● Use in patient who unwilling or too unwell to undergo VATS procedure

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 ● Tension pneumothorax
○

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